Ep. 549 Liquid Embolics: Practical Applications and Techniques with Dr. Gary Siskin

In this episode, host Dr. Aaron Fritts interviews Dr. Aneesa Majid and Dr. Roger Tomihama about how an MBA can benefit physicians and their career goals, and how they both went about getting their MBAs as mid career interventional radiologists. The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/OrwQwd --- CHECK OUT OUR SPONSOR Athletic Greens https://www.athleticgreens.com/backtablevi --- SHOW NOTES We begin by discussing the paths these physicians took to get their MBAs, and what their individual goals were for this extra degree. Dr. Aneesa Majid works at VIR Chicago and is the CEO of Zipdata, a biotech company working to get rid of fax machines in health care. She completed her MBA at Kellogg before her move into the biotech industry. Dr. Roger Tomihama is an associate professor of interventional radiology at Loma Linda, a former navy doctor, and is just starting his MBA program at Wharton. They discuss the different types of MBAs, including the traditional MBA path and the healthcare specific MBA. They both recommend IRs do the traditional track because it opens up many more networks outside of the physician community, and allows you to develop a business mindset, which may be more limited in a group of physicians only. Dr. Tomihama recommends talking with both physicians and non physicians who have done MBAs to better understand the culture and the expectations before signing up. It is important to do your research about which institution is best for your goals, as well as looking at specific program criteria. For example, some institutions don’t require physicians to take the GMAT before applying. Finally, we discuss how physicians can grow their business knowledge without getting an MBA. Many IRs need a better understanding of business especially if they are interested in starting an OBL. Dr. Majid and Dr. Tomihama recommend educational material provided on Coursera or AAPL as ways to gain important information without the huge time and monetary investment of an MBA, which is not feasible for all physicians, especially those who want to maintain their clinical IR practice. --- RESOURCES Coursera: https://www.coursera.org American Association of Physician Leadership: https://www.physicianleaders.org

1 Aug 20221h 11min

In this episode, guest host and vascular technologist Jill Sommerset interviews interventional radiologist Dr. Mary Costantino about the use of advanced arterial ultrasound in the setting of chronic limb-threatening ischemia (CLTI), especially in pre-procedural mapping. --- CHECK OUT OUR SPONSOR Boston Scientific Eluvia Drug-Eluting Stent https://www.bostonscientific.com/en-US/medical-specialties/vascular-surgery/drug-eluting-therapies/eluvia/eluvia-clinical-trials.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-de_portfolio-hci&utm_content=n-backtable-n-backtable_site_eluvia_1&cid=n10008043 --- SHOW NOTES Jill and Dr. Costantino describe the workflow at their practice and discuss how ultrasound findings can be translated to drawings that help with interventional planning. Dr. Costantino says that ultrasound is traditionally seen as a mundane part of radiology training, but it can be extremely useful if it is operated and interpreted by a skilled technologist. In fact, Dr. Costantino often relies solely on ultrasound to map CLTI patients, instead of diagnostic angiograms. She believes that ultrasound can provide more information about blood flow characteristics and cap morphology. Dr. Costantino also favors ultrasound over TBI and ABI measurements, since the latter values are usually inaccurate in diabetic patients. We look at examples of successful cases where ultrasound results affected access points, how the cath lab setup, and the overall efficiency of the procedures. Jill highlights the use of ultrasound in the immediate post-procedural period. This often shows immediate improvement in pedal acceleration time (PAT). Patients are also followed up after two weeks to ensure that the PAT is sustainable. To end the episode, Jill discusses the current state of complex arterial duplex education. She recognizes the need for more technologists to be trained in this modality. Additionally, Jill describes how ultrasound findings can be used in the context of multidisciplinary limb salvage meetings in which interventional radiologists, interventional cardiologists, vascular surgeons, and podiatrists engage in cases together. Jill believes that the first step to integrating advanced ultrasound is to invest in training for vascular technologists. --- RESOURCES Advanced Vascular Centers: https://advancedvascularcenters.com/ Society for Vascular Ultrasound (SVU): https://www.svu.org/ HENDOLAT: https://www.hendolat.com/

29 Juli 202237min

In this episode, host Dr. Michael Barraza interviews Dr. Kyle Cooper, interventional radiologist and Dr. Tahmeed Contractor, electrophysiologist about how IR and EP work together at their institution, including how they perform complex pacer lead removals, and how the have embraced collaboration over competition. --- CHECK OUT OUR SPONSOR Inari Medical https://www.inarimedical.com/ --- SHOW NOTES The doctors begin by discussing how they began working together. It was somewhat by chance that they started to work so closely, because the EP and the IR labs are directly across from each other at Loma Linda, where they work. They both began finding patients that had overlapping problems requiring intervention by both specialties, such as someone who needed a pacer lead out who also had an occluded AV fistula on the same side. Their relationship developed further due to the nature of the complexity of some of the EP cases. They often have to remove multiple pacer leads that were placed in the patient over 30 years ago. When these devices were created, they were not designed to be removed, so it is often quite difficult to do. Furthermore, because they are mostly plastic, not metal, they often break during removal. When this happens, it is not uncommon to have to call IR to help retrieve the piece. Though a cardiothoracic surgeon is usually always scrubbed into EP cases, open heart surgery is only done if all else fails. The two discuss how this collaboration has allowed them both to learn new skills. Dr. Contractor now does many lead extractions and will only call Dr. Cooper if there is a complication. Similarly, Dr. Cooper says he has learned many techniques from Dr. Contractor such as how to use intracardiac echo (ICE), or more commonly called intravascular ultrasound (IVUS) in IR for many more procedures than he was previously able to. Some of the challenges they have encountered is reimbursement and scheduling. With EP, CT surgery and IR are all in the room and helping, it complicates who gets paid. In general, IR bills for any venoplasty done during the procedure, and EP and CT surgery bill for the rest.

25 Juli 202250min

Host Aparna Baheti interviews Barbara Hamilton and Aarti Luhar about navigating training and early career during a pregnancy. They discuss factors to consider such as scheduling, parental leave policies, radiation exposure risks, and childcare. --- CHECK OUT OUR SPONSORS Athletic Greens https://www.athleticgreens.com/backtablevi Medtronic Abre Venous Stent https://www.medtronic.com/abrevenous --- SHOW NOTES Our guests start by sharing their paths to motherhood. Dr. Luhar was pregnant as a diagnostic radiology trainee, while Dr. Hamilton was pregnant as an attending. We talk about the benefits of being part of a large department or group during maternity leave, due to more flexibility of scheduling changes and availability of coverage. Both of our guests recommend that IRs reach out to their HR departments as soon as they feel comfortable sharing their pregnancy news. Establishing contact with the department is a helpful way to clarify parental leave policies, specifically if one qualifies for parental leave and how long the leave can be. Additionally, Dr. Luhar encourages listeners to reach out to colleagues who have been pregnant before, since they can be a valuable resource for insights on the granular details of practicing IR while pregnant. In terms of radiation as an occupational exposure, Dr. Hamilton did not change her caseload during pregnancy. She shares her preference to wear extra radiation protection around her waist. Dr. Luhar reached out to her hospital’s radiation physicist for guidance. She received the advice to use standard radiation protection and follow the principle of ALARA (as low as reasonably achievable). Additionally, we discuss the risks of pathogen exposure and needle sticks. Both doctors agree that having supportive staff and colleagues can make the pregnancy process more manageable. Additionally, we discuss unexpected challenges during pregnancy. Dr. Hamilton describes her experience with the risk of premature labor and bedrest. Dr. Luhar recounts the struggle of scheduling prenatal appointments and dealing with pregnancy complications while working a full caseload. We close the episode by giving advice for evaluating the culture of your work environment, relying on support systems that are in place, and not being afraid to ask important questions. --- RESOURCES Dr. Barbara Hamilton Twitter: @TSuperheroine Dr. Barbara Hamilton Instagram: @TiredSuperheroine SIR Pregnancy Toolkit: https://www.sirweb.org/practice-resources/toolkits/pregnancy-toolkit/

22 Juli 202257min

In this special crossover BackTable episode, Dr. Aaron Fritts and Dr. Julie Wei talk with Dr. Gerry Mattia, Chiropractor and Director of Rehabilitation of ViscoGen Clinic in Orlando, Florida. The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/UmeBWU --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- SHOW NOTES First, Dr. Mattia recounts his journey to becoming a chiropractor, beginning with his medical history of aortic stenosis fixed by a chiropractor, his decision to enter chiropractic school, and starting his independent practice after graduation. Then, he explains how he deals with patients presenting with degenerative disc disease with spinal stenosis, which was the issue he resolved in Dr. Wei. A herniated disc is the most common cause of degenerative disc disease. The standard chiropractic treatment is cervical decompression to help the disc restore itself. Dr. Mattia also uses a level 4 laser to rehydrate the disc. For optimal results, he recommends that patients see him 4 times a week for 6 to 8 weeks in order to fully lift the pressure off of the brachial plexus. He notes that good chiropractors will use the correct formulas and appropriate technology while adjusting the patient gently. Next, the doctors delve into why many physicians are wary of chiropractors, which is rooted in a 1988 legal case that prohibited doctors from referring their patients to chiropractors. Dr. Mattia encourages physicians to seek therapy before medical issues develop into very severe conditions. Additionally, Dr. Wei notes that medical culture often encourages physicians to put the health of their patients before theirs. Then, Dr. Mattia discusses how younger people and surgeons can improve their neck health. He notes that excessive cell phone use can reverse the cervical curve, causing people to lose their normal lordotic curve, a structure which usually prevents compression. He also recommends strengthening the muscles in the neck and shoulders, sleeping with a cervical pillow, and going to a good chiropractor to get routine adjustments. Dr. Wei recommends avoiding slouching and adjusting screens to eye-level in OR. Both Dr. Wei and Dr. Mattia agree that maintaining a healthy body weight will have positive benefits on spinal health. Finally, Dr. Mattia recommends which qualities to focus on when finding a good chiropractor. He recommends looking for an experienced, passionate family practice chiropractor. As a word of caution, he warns listeners to never let a chiropractor adjust them without reviewing their X-ray imaging first.

19 Juli 202250min

Dr. Shamit Desai talks with Dr. Kavi Devulapalli and Dr. Vishal Kadakia about Locums work, including the current market and opportunities, different practice models, navigating finances and taxes, and how to organize your life around this unique practice style. Meet the locums chameleon! --- CHECK OUT OUR SPONSOR Medtronic Abre Venous Stent https://www.medtronic.com/abrevenous --- SHOW NOTES To start off, we discuss what locums means for each of these clinicians, including inpatient vs outpatient work. Most locums opportunities are in mid-sized cities and smaller cities, due to increased demand in these areas. Locums work is a way for IRs to take control of their practices, making it a very appealing work model. The ratio of IR to DR for each of these clinicians ranges from 70:30 up to 90:10. Employers need locums to prevent burnout of their FTE employees, and to reduce call in areas where IRs are overworked. Employers also look to locums to build service lines and bring in procedures that aren’t currently being done at their institutions. It is a rewarding opportunity for both employer and employee. Next, we review job expectations and the difference between inpatient and outpatient locums work. There are generally two types of clients, one needing someone to fill the role of a person who works at FTE, and another where the IR department is made up of a roster of rotating locums providers. Being in locums, you get exposure to so many different people, and practices and you get to expand your network. This opens up many opportunities that you would not get at one location. Some of the downsides are the need to constantly adapt, use equipment you are not as familiar with, and work with staff who do not know your preferences or even glove size. However, you get to build your schedule, and you have the power to work where you want when you want. Finally, we discuss some of the contracts, reimbursement, and insurance details. The three discuss the differences between being a W2 employee versus a 1099 employee, comparing what happens with health insurance and retirement. They also discuss the pros and cons of a 1099 versus owning an LLC versus starting an S corporation. All three physicians highly recommend researching these and speaking to a lawyer about your best options until you fully understand these concepts. They discuss licensure, credentialing and malpractice insurance, as well as whether they recommend using an agency for these as a locums. Lastly, they discuss reimbursement, including models such as a flat rate for a week versus a deconstructed model that consists of a daily rate, a call rate, and an overtime rate. --- RESOURCES Kavi Devulapalli Profiles Twitter: @linemonkeymd Blog: https://linemonkeymd.com Vishal Kadakia Profiles LinkedIn: https://www.linkedin.com/in/theirdoc

18 Juli 20221h 38min

In this episode, our guest host Dr. Vishal Kumar interviews medical anthropologist and social scientist Dr. Kelly Knight of UCSF. They discuss the meaning of structural competency, methods for incorporating this concept into medical education, and how it can be applied to alleviate physician burnout. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/4GAyUy --- SHOW NOTES Dr. Knight starts by defining structural competency as the recognition of the underlying policies, systems, and hierarchies that produce social determinants of health. While these structures may sometimes be invisible, they have a large impact on health outcomes. Examination of these factors allows us to think about interventions that can make healthcare more equitable. Next, we highlight effective ways to integrate structural competency into medical education. Dr. Knight shares information about national shared curricula that are designed with the flexibility for each institution to modify the content according to their community’s needs. Finally, we examine redlining as an example of structural violence, signifying intentional disinvestment in marginalized communities. Dr. Knight believes that change starts with an initial acknowledgement and recognition of policies that make populations vulnerable to illness. She also encourages individual healthcare providers to take action by developing interpersonal communication skills, strategizing ways to make the clinical space more focused on healing, and working with elected individuals to create equity at a policy level. All of these efforts may allow for healthcare providers to reconnect with their original motivation to help patients and have a protective effect against burnout. --- RESOURCES Structural Competency Working Group: https://www.structcomp.org/ Teaching Structure: A Qualitative Evaluation of a Structural Competency Training for Resident Physicians: https://pubmed.ncbi.nlm.nih.gov/27896692/ Mountains Beyond Mountains: The Quest of Dr. Paul Farmer: https://www.amazon.com/Mountains-Beyond-Tracy-Kidder/dp/0812973011 The REPAIR Project: https://repair.ucsf.edu/home Do No Harm Coalition: https://www.donoharmcoalition.org/ UCSF Health Equity Collaborative: https://thecollaborative.ucsf.edu/training-health-equity-collaborative

15 Juli 202239min

In this episode, host Dr. Mary Costantino interviews Dr. Kathy Krol, interventional radiologist and former SIR president about the evolution of interventional radiology, her various leadership roles, and the growth of women in IR. --- CHECK OUT OUR SPONSOR Inari Medical https://www.inarimedical.com/ --- SHOW NOTES We begin by discussing how Dr. Krol entered the field of radiology and subsequently became involved in special procedures in radiology, before the beginning of interventional radiology. At the time, there was only a 7 French stiff wire, a J wire, or a straight wire. She recalls how the introduction of two key instruments, the glide wire, and the stent, changed the entire practice and scope of the types of interventions radiologists could do. Next, Dr. Krol talks about her involvement with SIR (Society of Interventional Radiology). She first joined a meeting at a hotel in San Francisco, where she was the only woman in the room, and repeatedly mistaken for a nurse. At the time, the society had recently allowed women to join, and since joining, she has never missed a SIR annual business meeting. During her time as the president of SIR, in 2006, some of the main issues were preserving IR as its own field among vascular surgery and interventional cardiology, forming an independent IR residency, and forming the idea of the outpatient-based lab (OBL) as a new space for IRs to work in. Dr. Krol shares stories of her struggles as a woman in IR as well as in leadership positions. She began in radiology, where she had to work hard to learn procedures, and then even harder to prove to colleagues that she was capable. She was often mistaken for a tech or a nurse and resorted to wearing suits instead of dresses while in the IR suite performing procedures. She often had to take whatever role was given, but she used this to her advantage. One such instance is when she wanted to volunteer for SIR, they put her in coding and billing which was not her interest. She turned this around and became so invested in it that she has now helped create nearly all the CPT codes that exist for IR today.

11 Juli 20221h 17min